AP-Physiology

AP-Physiology

Exercise Physiology Service Enquiry, Pre-Screening, and Background Info Form
Full Name

First NameLast Name
Phone Number and Email

Phone NumberEmail- example@email.com
Local Suburb
Example- Hillarys
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDay / Month / Year
Health & Injury History
Do you have any injuries, past or current?

Other
Do the injuries previously mentioned impact your exercise? (If yes, please provide as much specific detail of your injury as you know.)
Have you been told that you have any of the below by a health professional?

Other
Exercise History & Goals

Consent and Private Health
What are your primary health goals?
Are there any current obstacles that would prevent you from reaching your goals?
Do you have a Referral? Please state type of Referral below (example: Medicare)-
From your GP/Specialist/Other.
Do you give consent for one of our Exercise Physiologists to contact you, and also give consent for any recommended exercises or treatment that may be discussed with you?
Verbal consent to treatment will be discussed in person.
Private Health Fund Provider?
Example- HBF. (Write N/A or None, if no Private Health)
Gym Access Disclaimer

Your responses help us build the most appropriate treatment pathway for you.
Exercise Treatment will be tailored specific to your needs or requirements. If clinically recommended, gym-base exercise may be advised. AP-Physiology conducts majority of services through GoodLife Health Clubs gyms. Initial consultations can be complete without paying fees or a gym membership, however facilities may require payment of a casual fee ($30), or an active membership for any continued access. Do you currently have an active gym membership, are you looking to get enrolled into a membership, or seek home/other treatment options?

Other
What are your available days and times to perform exercise?
Have you considered a budget for achieving your health, fitness, or rehabilitative goals? ($ per/week)
How did you learn or hear about us as an Exercise Physiology business?
AP-Physiology.com.au

Check out our website for more info!
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Health & Injury History

Exercise History & Goals

Gym Access Disclaimer

AP-Physiology.com.au